A person on Medicaid could get a gift card for eating a healthy diet or losing weight. Re-admitting a patient for the same condition within 30 days of his or her discharge could lead to a loss of money for a hospital.

Using an emergency room for nonemergency situations could trigger copays that range from $6 to $50 for certain Medicaid recipients.

School-based clinics would open their doors to adults. And Native Americans would be required to join the state's managed-care system.

On Tuesday, Gov. Susana Martinez's Human Services Department secretary, Sidonie Squier, unveiled a long-awaited blueprint of proposed changes to Medicaid, the government's low-income health-insurance program, in a series of presentations.

The 28-page document is the latest step in an arduous process that continues Monday, when Squier is scheduled to appear in Washington before federal officials to formally request that New Mexico be given flexibility to manage the state's Medicaid program.

"I think they're going to like it," Squier said of the plan. "There are a lot of states asking for things that people in this state would think are much more egregious."

It's unclear how federal officials will greet Squier's request. A final answer is likely months away as the state and the federal government begin negotiating the amount of flexibility the state can have, state officials said Tuesday.

Meanwhile, New Mexico's Medicaid advocates and recipients will pore over the document, wondering how the proposed suggestions might affect the 560,000 New Mexicans enrolled in the program. Ever since the administration announced its plan, advocates, recipients and some lawmakers have expressed concern, even alarm, at the Martinez administration's decision to seek changes.

State officials said Tuesday that they tried to strike a balance.

The plan does not call for a cut in recipients' benefits. It does not try to limit individuals' eligibility for the health-insurance program. And the proposal to charge Medicaid recipients a copay for using an emergency room for nonemergency situations would affect only those who earn more than 100 percent of the federal poverty rate. A family of four earning $1,863 per month lives at the federal poverty level.

With the gift-card idea, they decided to use the carrot instead of the stick by rewarding good behavior instead of punishing bad, they added.

And the loss of money to hospitals for re-admitting patients would likely only affect urban facilities at first, state officials said.

Some lawmakers and advocates greeted the plan with both praise and wariness Tuesday.

The plan represented a repackaging of good policy ideas, said Sen. Dede Feldman, D-Albuquerque. "There really isn't much new here, but the devil is in the details."

For example, the plan calls for care coordinators to help Medicaid recipients navigate the complicated health care system. Feldman wondered who would do that. "Is it someone from the MCO [managed-care organization] who has a financial incentive to deny care?" she asked. Or would it be a nurse or doctor?

Bill Jordan, policy director at New Mexico Voices for Children, expressed both relief and frustration.

"I'm very pleased that they're not recommending any cuts in benefits and eligibility," he said. "We were concerned that there would be significant cost-sharing in their plan, and we are pleased that the cost-sharing is minimal. That's a relief to us."

But Jordan and Feldman both challenged the reason the Martinez administration has given for making changes to Medicaid: that it is too costly.

Squier has said repeatedly that New Mexico's Medicaid program is unsustainable.

Records show that Medicaid rolls grew by nearly 74,000 individuals from July 2008 to December 2010, pushing the program's total cost to around $3.9 billion. Most of that bill is footed by the federal government, but New Mexico's share stills comes to around $857 million a year -- a significant portion of the state's $5.4 billion general fund.

What's more, an additional 130,000 to 170,000 New Mexicans are expected to enroll in the state's Medicaid program in 2014, an expansion that could cost New Mexico hundreds of millions more by the end of the decade, state officials said.

But Jordan said the expansion of Medicaid would not only bolster New Mexico's economy, but add revenue to the state's coffers through services that will be taxed.

"Every time we have listened to these presentations, they always believe that Medicaid is unsustainable," said Jordan, who was briefed on the administration's plan Tuesday. "It's really our position that [that claim] is bogus. The revenue that is coming into the state from health care reform is in the billions of dollars. And the state's tax revenue from that will more than pay for New Mexico's share of Medicaid."

Feldman, who also was briefed on the plan, found the administration's argument misleading as well, adding that the cost of private insurance is rising at a higher rate than either Medicaid or Medicare, the federal program for the elderly and disabled.

Dr. Ron Lujan, a retired physician who practiced in the Grants area, meanwhile, called into question the administration's plan to require Native Americans to join the state's managed-care structure.

Currently, seven private-sector, managed-care organizations administer $2.46 billion of New Mexico's nearly $3.9 billion Medicaid budget. While the state wants to reduce the number of managed-care companies administering the program with its proposed changes, it wants to add Native Americans under the managed-care umbrella.

Lujan said something similar was tried in the 1990s, and it was an utter failure. "It didn't work the first time in the '90s," he said. "You had people in northwest New Mexico who were given providers in Roswell or Hobbs."

He added that the limited number of providers on Native lands would complicate plans. "You could set up a damn good managed-care plan, but if they're not out there, how do you care for the people?" Lujan said.

Squier acknowledged Tuesday that a lot of details must be worked out. She talked about how New Mexico could move forward with the proposal, of how the state could no longer pay for the quantity of Medicaid services offered but rather would have to focus on the quality of the outcome those services lead to.

The secretary also talked about expanding innovative programs, like one in use at University Hospital, in which doctors use Skype or teleconferencing technology to help doctors in rural or frontier areas. She hopes to see more hospitals participate.

As for use of school-based clinics, the state is still deciding whether to open them only in the evening or to allow adults into the clinics during the day, too.

"There is some question about having adults roaming around schools with kids there," Squier said, saying a final decision hasn't been made.

Contact Trip Jennings at 986-3050 or at tjennings@sfnewmexican.com.